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All rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Whilst I agree with the author that ‘patients are not offered enough choice in how illness at the end of life is managed’, offering someone the option of premature death, as the author implies, is not the solution. I am aware that as a Palliative Medicine Physician, the people whom I have the privilege to treat near the end of their lives only represent the tip of the iceberg of those who could benefit from palliative care.

Rather than devoting so many journal articles, podcasts and radio airwaves to the ‘assisted dying’ debate, the medical profession should instead be discussing what we can do to help those people who need our services whom we haven’t been able to reach. A review published in 2011 estimated that 92,000 people in England have an unmet palliative care need – this number could indeed be an underestimate.1

Until we address the barriers to accessing palliative care, we are missing the point. In my role as a Palliative Medicine Physician I regularly encounter patients, confronted with their own mortality, who are worried about being a burden to family or society as their condition deteriorates. How many more people are out there who feel this way, but do not have access to palliative care services for support?

Instead of polling its members about ‘assisted dying’, the Royal College should instead be asking, ‘what can we do to improve access to palliative care?’

Whilst I agree with Temple that ideally the full membership of all the colleges and the BMA should be given a say, the reality seems that any adopted view risks being that of an unrepresentative but vocal tiny minority. The reason for this seems to be the astonishing level of apparent apathy and avoidance of involvement in ethical, political and legal matters amongst the medical profession. The stark contrast to this position appears to lie within the palliative care cohort, who are clearly motivated by other personal factors (1). Unfortunately Regnard et al do not provide details of numbers polled or response rate in citing 92% opposition to a change in the law.

If for no other reason, it is this significant level of avoidance of involvement that should dictate the adoption of a neutral stance by all of the bodies.

The RCP are attempting to redress the balance. I am not aware of any similar intention from the RCGP. The RCGP position remains opposition (2). It is worth examining how that position was confirmed in 2013. Reading their report pdf (3) raises some concerns for such an important subject.

Through various routes the RCGP contacted the membership. The RCGP claims to represent over 50,000 UK GPs (not all are RCGP members). Only 234 (0.47% of GPs) responded directly to the college. Of these 77% (0.36% of GPs) were opposed to legalised assisted dying.

Aside from this vote the college took into account the finding of 28 various individual devolved bodies, faculties and committees. By some combining this was reported back as 24 bodies. The college reports that 20 of the bodies supported the college opposition to a change in the law. The number of GPs making up each of these bodies forming this view merits inspection. There was no apparent attempt at consistency or uniformity regarding methodology, which adds more than a sense of vagueness to the outcome. It seems in some cases that double counting of views may have occurred. The total number of participants appears to be about 1425 with an average of 59 per group. The range is interesting with the smallest group being only 3 in number. In the analysis the opinion of this group of 3 carried as much weight as the largest group of 416. Similarly only four groups contained more than 100 and four contained less than 10. This methodology renders the outcome less than reliable.

For a college that has actively promoted the importance of evidence, the firm conclusions drawn and stance taken are highly questionable. The use of these results to claim the representation of the opinion of UK GPs is not justified. We simply do not know the overall majority view. It is clear that at present the only appropriate position to adopt is neutrality.